Middle mesenteric artery: contraindication to endovascular repair of an abdominal aortic aneurysm?

Middle mesenteric artery has been described in 1923. We report the observation of a patient with an abdominal aortic aneurysm who had this rare artery arising from the anterior wall of the aneurysmal sac. His inferior mesenteric artery was occluded at its origin from the aorta and the middle and the distal colon was vascularized only by the middle mesenteric artery. Occlusion of this artery would have been necessary before endovascular repair of the aneurysm. We were concerned about the risk of colic ischemia after the occlusion of the middle mesenteric artery, so we abandoned this approach and operated on the patient via a laparotomy. Based on a case report, we here report a literature overview on the repair of abdominal aortic aneurysm in the presence of a middle mesenteric artery.

Stenting of a spontaneous dissection of the superior mesenteric artery: a new therapeutic approach?

Spontaneous dissection of the superior mesenteric artery (SMA) is rare and has been reported only sporadically. Therapeutic options are either a surgical approach, which is the more frequently adopted, or a simple observation. We report a case of spontaneous dissection of the SMA with a review of the literature and present a new therapeutic approach.

Extrahepatic arterioportal fistula: three-dimensional reconstruction of computerized tomodensitometric scan for diagnosis and morphologic assessment.

Arterioportal fistulae (APFs) are rare. An asymptomatic APF was suspected by computed tomography. Multiplanar, maximum intensity projection, and surface shaded display reconstructions showed its anatomy. To our knowledge, this is the first report using such reconstructions to analyze the architecture of an extrahepatic APF. Complete assessment of APF can be achieved noninvasively, and initial endovascular treatment can be planned.

Routine use of intravascular ultrasound for endovascular aneurysm repair: angiography is not necessary.

INTRODUCTION: to assess the outcome of endovascular aortic aneurysm repair (EVAR) using intravascular ultrasound (IVUS) without angiography. MATERIALS/METHODS: eighty consecutive patients (median age 69 years (range 25-90): male 72 (90%), female 8 (10%)) underwent endovascular aneurysm repair (AAA 68 (85%), TAA 12 (15%)) using either angiography in 31/80 patients (39%) or IVUS in 49/80 patients (61%) in accordance to the surgeons preference. RESULTS: hospital mortality was 2/80 (3%), 1/68 for AAA (2%), 1/12 for TAA (8%), 2/31 for angiography (7%), and 0/49 for IVUS (0.0%: NS). Median quantity of contrast medium was 190 ml (range: 20-350) for angiography versus 0 ml for IVUS (p<0.01). Median X-ray exposure time 24 min (range 9-65 min) versus 8 min (range 0-60 min) for IVUS (p<0.05). No coverage of renal or suprarenal artery orifices occurred in either group. Conversion to open surgery was necessary in 4/80 patients (5%), 1/31 for angiography (3%) and 3/49 patients for IVUS (6%: NS). Early endoleaks were observed in 13/80 patients (16%): 8/31 patients for angiography (26%) versus 5/49 for IVUS (10%: p<0.05): 5/13 endoleaks resolved spontaneously (39%) whereas 8/13 (61%) required additional procedures. CONCLUSIONS: IVUS is a reliable tool for EVAR. In most cases, perprocedural angiography is not necessary.

[Surgical therapy of complicated sigmoid diverticulitis: single stage or multi-stage operation?]. / Chirurgische Therapie der komplizierten Sigmadivertikulitis: einzeitig oder mehrzeitig?

Surgical tactics for the teatment of complicated diverticulitis are in constant evolution and remain a subject of controversy. Amongst 53 patients operated on for complicated sigmoid diverticulits over a 10 year period in our hospital, 29 underwent a Hartmann's procedure (3 Hinchey's stage II, 19 stage III and 7 stage IV). Only 11 out of 20 having survived the operation underwent restoration of bowel continuity (55%). This experience is in line with the literature. Surgeons have become conscious that in reality the colostomy was permanent in a significant proportion of patients who were poor candidates for a second operation. Therefore there is a tendency to perform as far as possible a resection of the sigmoid and a colo-rectal anastomosis in a one-stage procedure. In the absence of prospective randomized studies and objective criteria, the decision to resect the sigmoid in a one-stage or in a multi-stage procedure is based on consensus and clinical judgement.

[Pneumatosis intestinalis: a rare and difficult problem]. / La pneumatose intestinale: un problème rare et difficile.

We present a case of a 74-year-old-woman who developed 3 episodes of intestinal pneumatosis, 2 times complicated by pneumoperitoneum, with consequent lethal outcome after 4 months. Intestinal pneumatosis, according to the literature, is a difficult and rare problem, associated with a large number of current diseases, can be complicated by pneumoperitoneum, mostly without clear etiology, whose treatment remains empirical (antibiotics, O2-therapy), not excluded laparotomy, if the clinical situation requires it.

Industrially manufactured all-in-one solution in visceral surgery.

OBJECTIVE: The goal of this study was to examine the handling and the effect of a commercially manufactured nutritional solution (VacuKit zero 1) on the postoperative metabolism and the liquid requirement after gastro-intestinal surgery. DESIGN: Open, prospective, nonrandomized study. SETTING: Ward of the visceral surgical department of a town hospital in Switzerland. PATIENTS: 36 consecutive patients after gastro-intestinal surgery. INTERVENTIONS: During the first 5 postoperative days 2,000 ml of the commercially manufactured nutritional solution were administered daily; it was composed of amino acids (100 g), glucose (1,120 kcal), fat (820 kcal) and electrolytes. RESULTS: The nitrogen balance in the postoperative phase was always positive. Laboratory analysis shows that this nutrition solution is well accepted, with stable carbohydrate and fat metabolism and with normal liver and electrolyte parameters. The patients received an average of 500 ml/24 h of additional liquids. CONCLUSIONS: Administration and handling of the solution VacuKit zero 1 requires no special equipment. The nutritional solution proved to be a safe and simple method of parenteral nutrition for metabolically stable patients in the visceral surgery department.

[Castleman's disease]. / Morbus castleman.

A 17-year-old girl developed acute colicky periumbilical pain with haematuria. On examination a tightly elastic space-occupying lesion about 10 cm in diameter was palpable around the umbilicus. Erythrocyte sedimentation rate (ESR) was raised to 113 mm in the first hour. There was a microcytic anaemia (8.7 g/dl) and a positive Coombs test. Ultrasonography revealed a periumbilical space-occupying lesion of decreased echogenicity and left hydronephrosis. Computed tomography demonstrated a homogeneous noninfiltrative tumour, about 7 cm in diameter, with increased contrast medium concentration. The tumour, which was covered by peritoneum and well circumscribed, was excised from the base of the mesentery. Histologically it proved to have hyaline-sclerotic changes in the blood vessels and lymphoid and plasma cellular infiltrations, corresponding to a mixed form of Castleman's disease. In a second operation a left nephroureterectomy was performed. The kidney, the regional lymph nodes and the tissue which had caused the stenosis of the ureter all showed the same changes as the tumour. Postoperatively the ESR and the blood count became normal, but the Coombs test remained positive. During a subsequent pregnancy the ESR again rose. The patient has remained symptom-free for 38 months after the second operation.

Helicopter mountain rescue of patients with head injury and/or multiple injuries in southern Switzerland 1980-1990.

The aim of prehospital treatment of head injuries and severe multiple injuries is to prevent additional cerebral damage. When accidents occur in remote mountain areas, time is lost covering the distance to the nearest cabin or village where the rescue team can be called by telephone. Rapid transport of a trained physician to the patient can save precious time and allows prompt control of respiration and circulation at the scene of the accident. In a series of 57 rescue operations between 1980 and 1990, we used a helicopter staffed by an emergency physician and equipped with a winch. The hospital mortality rate was 12 percent (7 out of 57 patients). At 6 months after the accident, a normal neurological state was registered in 44 of the 55 survivors (88 per cent), whereas mild neurological deficiencies were noted in six patients (12 per cent). No persistent coma or vegetative state was seen. This experience suggests that fast rescue by a helicopter equipped with a winch and with an experienced emergency physician on board in an effective way of preventing secondary cerebral damage after accidents in remote mountain areas.

[Emergency medical system in Bellinzona (South Switzerland): a sensible, affordable model with use of ambulance and helicopter]. / Notarztsystem in Bellinzona (Südschweiz): ein sinnvolles, kostengünstiges Modell mit Einsatz der Ambulanz und des Helikopters.

Use of a mobile coronary care unit is a well recognized institution, but it often fails because of excessive costs. By means of an emergency physician working in the intensive care unit we have organized an economical rescue system by both helicopter and ambulance meeting the requirements of pre- and hospital treatment of the patients.

[Utilization of helicopters for the prevention of secondary cerebral lesions in severe craniocerebral injuries]. / Helikoptereinsatz zur Vermeidung zerebraler Sekundärschäden bei schweren Schädelhirntraumata.

The prehospital emergency treatment of craniocerebral trauma tries to avoid secondary cerebral lesions by controlling respiration and circulation. The therapy consists of heavy sedation with Midazolam, analgesia with morphine, artificial hyperventilation, PaO2 over 12 kPa and average arterial pressure above 80 mmHg. Our series of 46 patients recovered between 1982-1988 had a hospital mortality of 23%. 46% of the patients were polytraumatized. A normal neurologic state 6 months from the accident was registered in 86.4%. For 13.6% it was slightly pathological and no vigilant coma state was reported. The most effective rehabilitation method at the site of the accident has to secure the cerebral oxygen supply and reduce potential increase in intracranial pressure for avoid secondary cerebral lesions.